Use this form to request an autelic.org account for the Demo App. Fill in the details below and hit send. We will process your request and reply to you by e-mail shortly.<br>
<br>
  {% if error_message %}
  <div style="color: red">{{ error_message }}</div>
  {% endif %}

  <form action="send">
    <fieldset style="border: 0">
      <label for="first_name">First Name:</label>
      <input id="first_name" type="text" name="first_name">
      <br>
      <label for="last_name">Surname:</label>
      <input id="last_name" type="text" name="last_name">
      <br>
      <label for="email_address">Your e-mail address:</label>
      <input id="email_address" type="text" name="email_address">
      <br>
      <label for="message">Include a Message</label>
      <textarea id="message" name="message" rows="6" cols="80"></textarea>
    </fieldset>
    <input type="submit" value="Send Request">
  </form>
  
</body>
</html>
